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Psychopathology Sum-Up: Bipolar Disorder

[Content note: brief discussion of suicide]

Weekly series! As per previous discussion, I will be published a big information blog about a specific mental illness on each Friday.

I know, today is not Friday. I’m publishing early because I’m excited, and also I want to get lots of feedback. Tell me what I’m not including, what other things you want to know, etc. If there’s enough questions, I’ll do a second follow-up post. Lastly, tell me if there’s terms I’m not defining that I should be. I really really don’t want to get wrapped around jargon here–it helps nobody.

The idea is to talk about what the diagnoses are and aren’t, common misconceptions, what treatment and outcomes look like, and so on. Though not all therapeutic orientations (the theory and approach behind a course of treatment) depend on or use diagnoses–and there’s some very good arguments against using the medical model of diagnosis–we do use labels to conduct research, and it’s worth learning what a mental illness is. I’m going to try to include any changes to diagnostic criteria as well as current debates.

This post is massive and organized in informational sections, so I’ve put it behind a jump.

Words of Note:

DSM: The acronym for the Diagnostic and Statistical Manual of Mental Disorders, a five axis classification system. We’re currently on DSM-IV-TR (TR being ‘text revision’). The DSM is atheoretical–it proposes no reasons for development of disorders, only means of identification. The DSM5 is predicted to be released in 2013, but it’s been put off so many times that it may change. More information here.

Comorbidity: A second disorder appears together with the initial diagnosis. For instance, depression is highly comorbid with anorexia nervosa. High levels of comorbidity can actually be a sign that the diagnosis is less accurate than it could be. To use the previous example, what if we’ve just misdefined anorexia? What if anorexia actually is a disorder that usually includes features that look like depression, but isn’t a wholly separate mental illness? Genetics and neuroscience research can come in handy here, and disentangling these things contributes to some of the reason we revise the DSM.

The Overview:

Bipolar disorder used to be known as manic depression or manic-depressive disorder. It is similar to depression in that in both cases, major depressive episodes are present. However, just the presence of a single manic or mixed episode results in a diagnosis of bipolar instead of depression.

Also like its unipolar counterpart, BD is highly heritable, meaning that genetics play a large role in the development of the disorder. Twin studies have been fairly small scale, so we can only estimate exactly how much, but it’s roughly 70%. There’s also some evidence that the manic and depressive aspects of the disease are inherited separately. This is born out in that children of parents with BD may inherit, with approximately equal risk, bipolar or unipolar depression. [More information here]

I also want to note here that just because there’s both mania and depressive episodes in BD does not make the lows somehow less distressing than in depression. I’d suggest viewing the disorder as having depression and having mania. Secondly, please remember that it just takes a single episode of mania or hypomania to receive a BD diagnosis–it’s possible to have BD and spend the majority of your time with major depressive episodes.

Bipolar Disorder Subtypes:

Cyclothymia: could be described as ‘mild’ version of bipolar. Moods never meet full criteria for mania, or major depressive episodes, but come close to both.Bipolar I: Include at least one fully manic episode and major depressive episodes, each lasting at least seven days.Bipolar II: Like BD I, but without reaching full mania or having mixed episodes. Both subtypes have equal rates of suicide attempts, though there’s research indicating those with BD II use more lethal means in their attempts (such as guns). [Note from twitterer Ally–because there’s no distinct mania, BD II can easily be misdiagnosed as depression.]Bipolar Not Otherwise Specified (BD NOS): The client doesn’t quite meet criteria for any other subtype, but is experiencing clinically significant distress that aligns most closely with BD. For instance, a client who experiences manic episodes that last four days at most, and meets criteria for having depressive episodes.

Rapid-Cycling: Any of the previous subtypes can carry this secondary label, which means having more than four episodes per year. That’s considered to be a higher-risk indicator, because of the constant polarity of mood.

Things Bipolar Disorder is Not:

Having a ‘mood swing’. Nope. It’s just not. Mania and depression are both incredibly distressing to experience, and it’s trivializing to compare that to a simple mood swing.

Schizophrenia/ADHD/Dissociative Identity Disorder. Apparently this is a common misconception. Those are all other diagnoses, and not even in the mood disorders category. Other things BD is not: the color blue, strawberry marmalade, and feeling happy and sad in the same day.

Mania, Hypomania, & Mixed Episodes

Mania & Hypomania: Bear with me here, because mania seems a touch like pornography–you know it when you see it. It’s basically a combination a large number of any of the following: restlessness, impulsive behavior particularly with things considered “high risk” such as sex and spending money, beginning projects, sleeping little, racing thoughts, and irritable mood. I want to emphasize that it has to be at clinically significant and distressing levels to qualify as mania. Sometimes we all bite off more than we can chew or feel restless. This is an overarching pattern of behavior outside of one’s control. People who have experienced this are welcome to speak up in comments.

Mixed Episodes: Mixed comes from the combination of depressive and manic symptoms. The two most definitely don’t cancel each other out, and mixed episodes are actually considered the worst. Take this easy example: Suzy has trouble with suicidal ideation. During mixed episodes she feels depressed, but also has lots of motivation and energy…which actually makes her more likely to follow through on a plan. Having had non-clinical levels of mixed feelings, I can assure you it’s horribly unpleasant. You feel awful, but you also can’t sit still or fall asleep or stay away from people. I want to crawl out of my skin.

Diagnostic criteria for Bipolar I Disorder[Edited slightly–the DSM actually has criteria for Bipolar I divided out by most recent episode type. However, they’re almost entirely identical]
A There has previously been at least one Manic Episode or Mixed Episode.
B. The mood symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
D. The mood symptoms in Criteria A and B are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

Diagnostic criteria for Bipolar II Disorder
A. Presence (or history) of one or more Major Depressive Episodes.
B. Presence (or history) of at least one Hypomanic Episode.
C. There has never been a Manic Episode or a Mixed Episode.
D. The mood symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
E. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
F. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Medications:

Mood stabilizers such as lithium, anticonvulsants (which may carry a risk of increased suicidal thoughts), and atypical antipsychotics (also known as second generation antipsychotics). Oddly, there’s been no evidence to suggest that anti-depressants are any more effective than mood stabilizers in treating BD. (citation) It’s also of note that St. John’s Wort, which is sometimes marketed as an herbal antidepressant, might actually cause an increase in mania, as well as cause other medications to stop working (It can also interfere with hormonal birth control–alt med is not harmless). (NIMH)

If any information is incorrect, please note it in the comments! However, I am going to ask for citations. I have access to journals as a student, so no worries if it appears behind a paywall. Also, please chime in with your own experiences, misconceptions, myths you’ve heard, and any book suggestions!

Hey. I just want to start by saying I think this is really ambitious but a great idea. I’ve known multiple people with type I or type II BD, but one in particular stands out in my memory (she was type I), because she had also experienced dissociative episodes (blacking out, but still conscious… just… not like herself), but only while drinking, and this only began when she started taking medication to treat her BD. So she didn’t want to tell anyone that she was taking medication, because she was terrified of being rejected by them for needing it to begin with.

Can I just say, DANGEROUS!

Also, some materials I’ve come across suggested that in place of depressive episodes in BD-II, some individuals (many, perhaps, I don’t know what would be more appropriate) experience persistent misdirected anxiety (i.e., not a result of a particular stimulus, but very much disabling), for the entire duration of time between hypomanic episodes. I don’t know if that’s what you’ve also found?

And I found a few papers while in my first year of psychology, that suggested that occasionally unrelated drug treatments (e.g., oral contraceptive, antibiotics) can actually trigger people to develop BD-II. These people are typically described as having a “bipolar personality”, and so there has been discussion about the possibility of classifying a BD-III.

I think it might also help other people who are less familiar or intimately acquainted with the lives of people who are living with BD of either type, if there was a bit more information offered about what constitutes a manic episode and how this is different from a hypomanic episode. I mean, I don’t know about you, but the only time I’ve stayed awake for four days was a battle against myself, and yet I have often heard of people in a manic episode doing ALL THE THINGS (like, paint the entire interior of a two-storey home unassisted) for four days non-stop without sleep, before a loved one, neighbour, or friend, finally tries to convince them to at least take a nap. A hypomanic episode might be half as bad by comparison (in terms of magnitude only — it’s still AWFUL and there’s no way of comparing quality-wise), while still highlighting how unusual it is for someone to just not ever get tired for a couple of days straight or a week at a time.

Oh, you make a lot of good points, so I’m going to respond in a list!
1) Manic vs. hypomanic. I’m under the impression that hypomanic episodes are manic episodes that don’t quite meet full criteria. HOWEVER, the googles are failing me, and I can’t seem to produce the current criteria for either state. I should have my hands on a psychopathology reference tomorrow, and I promise to come back to answering this.
1a) yes, doing ALL THE THINGS is one characteristic, and worth mentioning, thanks!

2) I’ve not heard or read anything about the causality of antibiotics or birth control–and though I’m hunting through psychCentral/PubMed, etc, I’m still not seeing anything. Could just be me though, so if you do find any sources, please share!

AND, because I seem to be unable to answer all of this in one comment, anxiety isn’t listed as a specific criteria for bipolar disorder, but BD is often comorbid with anxiety disorders of all kinds (social phobia, generalized anxiety, etc). It makes a little sense, if you think about how disconcerting it would be to not know which way the pendulum would swing, or when.

Thanks for the effort you put into this project. There are so many things that people are simply ignorant about (I mean that literally, not snarkily) and the more people trying to get real information out there the better.
Learning about BD in university was very different that learning about BD personally. I studied Psychology getting my BA in Psych in 2002, and felt that I had a basic understanding about many mental health issues. I also got married in 2002 and my wife is Bi Polar. Knowing “about” a disorder and really knowing the disorder are very different, the difference between reading a book and a trip to the hospital with your spouse bleeding from self inflicted cuts.
A few things that I want to share, coming from first a real respect for mental health research and science based medicine, and second from someone who is the first line of support for a real person with mental health needs.
Always beleive that there is hope and help. Not just those who are struggling with mental health challenges, but those supporting them. Many people are working constantly to make things better. Know that things do get better.
Be very careful of helpful people claiming miraculous cures. There are things that are helpful, there are things to take, medicinally and dietary supliments that are very helpful in the right circumstances, but there is no magic cure.
Have a support system in place, when you’re good, so that there are plans in place when things aren’t good. It is very hard to look for help when you are in crisis, much easier to have a plan ahead of time.
Thanks again for getting info out there.

Thanks for embarking on this! It’s great to have these resources in an accessible format – when I find out someone I know is ill with something, usually the first thing I do is Google as much info as I can on it (it’s how I cope – I’m a scientist and a nerd, so I’m a numbers person and so before any problem can be dealt with I must read all I can on it). Problem: A psychologist knows what those criteria actually mean, but laypeople can easily misunderstand. Thanks.

I know two people with BPI. Both tell me that manic episodes are more damaging to their overall life and livelihood than depressive episodes, but two data do not a trend make.

Regarding risk-taking: It’s important to note that the sort of risk-taking it talks about in manic phases isn’t just going skydiving spur-of-the-moment once. It’s part of an extreme pattern that can totally ruin someone’s financial security, career, and family life.

Hi, I was wondering if you plan to talk about schitzoaffective disorder at all later on in the series?

All right, back to bipolar:

I have a question about mixed states; I don’t know where I heard this from, but I’ve somehow gotten it into my head that for people who have a lot of mixed states their prognosis seems to be not very good. That also if you have a lot of mixed states and rapid cycle a lot that they can just get worse and worse each subsequent time?

Also that every time we stop taking our medication, like cold turkey, don’t need it any more can that make things worse for long term mental health? That it can get harder to treat each time you go off then go back on the medication? I think this would be good information to have especially for people who tend not to be so good at taking medicine or are looking for the right combination of meds.

I’m also sorry my writing isn’t very good right now, this is a time of year that my symptoms come up (almost like clockwork, starts the week before Christmas) I am having a really hard time stringing thoughts together. I haven’t slept in 2 and a half days. For some reason I find myself rapid cycling and in mixed states a lot.

I could talk about my symptoms more and share some stories in comments if that is appropriate

Oh one more thing, something actually kind of scary. I see sometimes suggested like trying to induce a hypomanic state and try to stay in it… to be able harness your creative power and excess energy and be in an elevated mood. It was completely ridiculous and frankly dangerous. I’ve seen people who are into this whole ‘exist in a state of hypomania’ though and I can totally understand the desire, luckily I’ve got a good support system to keep me from… testing out this theory!

And just want to clarify in case it was confusing, When I say stop taking our medicine in the 4th paragraph I mean in the ‘bad’ way, mistakenly thinking ‘haven’t had any symptoms in a month time to chuck the pills out’

I once had as a faculty advisor a very famous physician who was bipolar, knew it, and rejected the concept of mood stabilizers. He said he put up with the depressive episodes because he felt he was so much more productive during his manic phases.

We had this little test we implemented with him: When you wanted something from him, telephone him. First, say, “How are you?”…if his answer was “WONDERFUL!” proceed. If not, say “OK, I’ll call you back later” and hang up.

He did do things like spend a million dollars on renovating a place in San Francisco, then almost immediately decide to move to New York. Then move back to San Francisco 3 months later. So, his impulse control was pretty poor.

But he was a brilliant guy regardless of his mood status, and his staff positively adored him. I think they figured out the ways to push him past the depressive episodes.

1) I will talk about schizoaffective later, but I need to do some further research so that I can clearly dilineate between schizoaffective, schizotypal, schizophreniform, and schizophrenia in layperson’s terms.

2)Yes, presence of mixed states and continued mixed states do often suggest a lower prognosis.

3)Psychopharmacology isn’t my strong suit, so I don’t think I’m qualified to answer your medication question. The best I can give you is “I don’t know”. (I’m on a psychology track, rather than a psychiatry one.)

4) I’m sorry you’re having a rough time of it this season. I’m emphatically *not* a therapist, but if you want someone to listen and talk to, I can be found at donovanable at gmail dot com.

5)Please do share experiences if you feel up to it!

6) Yes, I think the fetishization of mania is a problem. You see it also in people who talk about how Van Gogh would have been a ‘lost genius’ if medication was available in his time. Yeah, maybe, but he also might not have died, and I think that matters more.

Excellent post. You avoided a lot of the misinformation out there. Two notes, though. First, APA announced (recently, I think) that they approved DSM-5 and that it would be published this year. Second, the reason you had trouble finding the criteria for hypomania is probably because the criteria are copyrighted. You probably shouldn’t post any of them. Sorry to be the bearer of bad news.

From the perspective of a non-psychologist with at best a cursory knowledge of most mental health illnesses, I found this very informative and interesting. Defining some of the more specialized terms and explaining their relevance to the discussion is incredibly helpful to one who is not familiar with them. Additionally, the format also helps convey the information well. The grouping used helps build connections for one with little prior knowledge of the subject. I think you hit a great balance between making it general enough to be easily accessible, but specialized enough to impart a wealth of new information and make it relevant to other psychologists. All in all, a great read and I am looking forward to seeing more on other mental health illnesses.

Thank you for answering all my questions and I am looking forward to that discussion! And thanks for putting it in a list made it nice and easy to process. This is mostly anecdotes, and decided to use a lot of “I statements” and add this disclaimer, I hope this wasn’t out of line.

I have been diagnosed with schizoaffective, but sometimes hesitant to describe myself as such. One of the reasons is that there seems to be disagreements on if it is a distinct disorder from bipolar and schizophrenia. I still find it very useful though since it acknowledges the bipolar-schizophrenia continuum, so I feel like I’m receiving the best treatment for me. I was able to mostly get the worse symptoms under control over a period of years and experimenting with different medication combinations (paranoia and disordered thoughts – I don’t like actually saying the words delusions, psychosis, violent thoughts, hallucinations though, thank you stigma – and the huge manic highs and deep lows). I consider meself exceptionally fortunate that through extensive, excellent treatment I can have insight into my illness and be able to recognise what is a symptom and fix myself. I know many people are not so lucky.

I know you’re not a therapist but I do find often reading your articles therapeutic in a sense. Especially in the last month or so after events like the Newton Shooting, to hear people like you and other activists speak out against all the misinformation and stigma with compassion and facts is invaluable. It wouldn’t be out of line to suggest that all this support helped prevent some people from being triggered into something really major.

That thing about Van Gogh reminds me that I’ve even encountered that woo-ish stereotype in professional treatment. One example I remember was from a CBT group, the topic came around to enjoyable activities and goals and someone mentioned art, painting. The worker leading the group made a similar comment about all the tortured mentally ill great artists (who coincidentally enough, seem to be sometimes diagnosed long after being dead – and amusingly seem to be post mortem-ly diagnosed with the exact same illnesses as the person doing it!)

Anyway, the instructor probably just meant to point out that art was a good way to express thoughts and emotions. Maybe it helped inspire some others in the group, but I didn’t find it too helpful because of the stereotype of tortured souls as great artists and great minds. Although it’s helpful to see people the same as you being successful and knowing that it can be possible to live a normal enough life

There is definitely a need to clarify on schizoaffective somewhere down the line, still a bit ashamed to derail on the bipolar thread, though I suppose it’s slightly relevant. I wouldn’t expect every lay person to memorise the literature of every illness but if they’re interested in learning more about a specific topic they can access the appropriate factual information, filter out the woo, and decide it would be of value to listen to take into consideration the experience of us *cough cough I am Adam Lanza’s Mother controversy*.

It’s also hard to write about mania, I have to ask the people around me who witnessed it and hope they’re being fair as possible because there are gaps in my memory and I’d want to be precise as possible. Plus I’d feel it more appropriate for a different forum thread. But that could be an interesting topic to explore, a skeptical analysis of memory loss/missing memories in manic episodes.

In my experience, Bipolar is very hard to diagnose. As a teen, I was diagnosed with Bipolar I and put on some heavy duty medications. They knocked out the extreme emotional disturbances and suicidal ideation, but also knocked out any ability to feel happy or creative. I went over a year without writing anything (beyond papers for school that were suddenly incredibly difficult after a lifetime of being able to write five pages 30 minutes before the deadline). When I was 19, another psychiatrist told me that I wasn’t bipolar, I had depression and anxiety. He took me off the medication, and it wasn’t very long before I was self-medicating with narcotic drugs (I had used painkillers for years without any addiction problems, and then in less then a year became a total addict). Got off the drugs, saw another psychiatrist who diagnosed me with Borderline Personality Disorder, PTSD, and OCD, but said I didn’t have Bipolar. After she rotated me though many, many differant drugs (at one point, I was on five seperate meds, all pretty heavy-duty; I was a drooling zombie, and completely non-functional), she eventually settled me on Wellbutrin and Ativan. After an insurance change, I had to change doctors, and found my current psychiatrist. She went back to the “depression” diagnosis, mostly because the Wellbutrin is working so well for me. She feels that my last doctor jumped the gun with the BPD and OCD diagnosis, mostly because I saw her just a month after being raped (which she knew), and after a couple years of therapy, she says I no longer meet the critera (I’ve heard this is common, which is why the last doctor shouldn’t have been so quick to diagnose me). So, now, on pape,r I am diagnosed with depression and PTSD. For what it’s worth, my therapist, who I have been seeing for over five years (through most of the different doctors), agrees with the current doctor. He was skeptical about the bipolar diagnosis and never believed that I had BPD or OCD, but has been with me through some serious depressive episodes and hospitalizations.

While I don’t think much of my previous psychiatrist, at least she started me on Wellbutrin, which Saved My Life, no lie. I am able to feel happiness for the first time in years. Unfortunatley, it does make the panic attacks worse, but that is a trade-off I’m willing to take in order to once again have the ability to feel joy.

So I don’t know. I know that as a teenager I had episodes that I would say meet the criteria for mania…I remember how my chest used to hurt with the excitement, the energy and undirected emotion, days without sleeping, starting seventeen different projects, grandiose dreams and plans, feeling like the rest of the world was so slow, not being able to stop talking, just bubbling over with feeling, unable to calm down even when it hurt. But I haven’t felt that way in years. And the Wellbutrin really helps and hasn’t caused a manic episode; I’m told that if I was truly bipolar, taking an anti-depressent without a mood stabilizer would really mess me up. ::shrug:: I’m not a doctor. I do the best I can to manage my conditions. Anyway, I’ve found that therapy and DBT help a lot more than medications, so mostly I work with a therapist to manage and control the symptoms, and I’ve stopped worrying about what label to put on it.

I hear you on this. It’s really made it difficult to get the help I needed over the last couple years. I had some very serious health problems (like, 15 surgeries in two years, easily could have died, actually shocked a couple of the surgeons by pulling through) and I’ve spent about 56% of the last two years in various hospitals and nursing facilities. Since this started, either because of the drugs, the medical problems, my previous mental health status, or all of the above, I experienced several episodes of paranoid delusions and both audio and visual hallucinations. It took me ages to finally tell someone, and I was terrified to talk to the doctors about what was going on. I probably made things more difficult for myself, in the long run, but I didn’t want to get labled “crazy”, I didn’t want people to start dismissing my feelings or concerns because, oh, she’s just unstable. Even though I was asked to always tell the nurse if I experience a hallucination, I rarely do. My last hospital stay, over New Years, I had a couple nurses who were already very dismissive and condescending, and I was having trouble getting them to take me seriously. I had no intention of adding to their disdain by mentioning, “Oh, hey, by the way, I just had a conversation with someone in the room who wasn’t actually there, and the voices in my head are keeping me from going to sleep.”

I just wanted to reply to thank you for sharing your story here and below in the comments. Especially the part about not being able to trust some health care professionals, sometimes I feel like I have to erect a barrier between physical and mental Heath because of a fear of being dismissed and not taken seriously.